23.6: The Evolution of Binary Star Systems
By the end of this section, you will be able to:
- Describe the kind of binary star system that leads to a nova event
- Describe the type of binary star system that leads to a type Ia supernovae event
- Indicate how type Ia supernovae differ from type II supernovae
The discussion of the life stories of stars presented so far has suffered from a bias—what we might call “single-star chauvinism.” Because the human race developed around a star that goes through life alone, we tend to think of most stars in isolation. But as we saw in The Stars: A Celestial Census, it now appears that as many as half of all stars may develop in binary systems—those in which two stars are born in each other’s gravitational embrace and go through life orbiting a common center of mass.
For these stars, the presence of a close-by companion can have a profound influence on their evolution. Under the right circumstances, stars can exchange material, especially during the stages when one of them swells up into a giant or supergiant, or has a strong wind. When this happens and the companion stars are sufficiently close, material can flow from one star to another, decreasing the mass of the donor and increasing the mass of the recipient. Such mass transfer can be especially dramatic when the recipient is a stellar remnant such as a white dwarf or a neutron star. While the detailed story of how such binary stars evolve is beyond the scope of our book, we do want to mention a few examples of how the stages of evolution described in this chapter may change when there are two stars in a system.
White Dwarf Explosions: The Mild Kind
Let’s consider the following system of two stars: one has become a white dwarf and the other is gradually transferring material onto it. As fresh hydrogen from the outer layers of its companion accumulates on the surface of the hot white dwarf, it begins to build up a layer of hydrogen. As more and more hydrogen accumulates and heats up on the surface of the degenerate star, the new layer eventually reaches a temperature that causes fusion to begin in a sudden, explosive way, blasting much of the new material away.
In this way, the white dwarf quickly (but only briefly) becomes quite bright, hundreds or thousands of times its previous luminosity. To observers before the invention of the telescope, it seemed that a new star suddenly appeared, and they called it a nova . 3 Novae fade away in a few months to a few years.
Hundreds of novae have been observed, each occurring in a binary star system and each later showing a shell of expelled material. A number of stars have more than one nova episode, as more material from its neighboring star accumulates on the white dwarf and the whole process repeats. As long as the episodes do not increase the mass of the white dwarf beyond the Chandrasekhar limit (by transferring too much mass too quickly), the dense white dwarf itself remains pretty much unaffected by the explosions on its surface.
White Dwarf Explosions: The Violent Kind
If a white dwarf accumulates matter from a companion star at a much faster rate, it can be pushed over the Chandrasekhar limit . The evolution of such a binary system is shown in Figure 23.18. When its mass approaches the Chandrasekhar mass limit (exceeds 1.4 M Sun ), such an object can no longer support itself as a white dwarf, and it begins to contract. As it does so, it heats up, and new nuclear reactions can begin in the degenerate core. The star “simmers” for the next century or so, building up internal temperature. This simmering phase ends in less than a second, when an enormous amount of fusion (especially of carbon) takes place all at once, resulting in an explosion. The fusion energy produced during the final explosion is so great that it completely destroys the white dwarf. Gases are blown out into space at velocities of about 10,000 kilometers per second, and afterward, no trace of the white dwarf remains.
Such an explosion is also called a supernova, since, like the destruction of a high-mass star, it produces a huge amount of energy in a very short time.  We call these white dwarf explosions type Ia supernovae.
We distinguish type I supernovae from those of supernovae of type II originating from the death of massive stars discussed earlier by the absence of hydrogen in their observed spectra. Hydrogen is the most common element in the universe and is a major component of massive, evolved stars. However, as we learned earlier, hydrogen is absent from the white dwarf remnant, which is primarily composed of carbon and oxygen for masses comparable to the Chandrasekhar mass limit.
The “a” subdesignation of type Ia supernovae further refers to the presence of strong silicon absorption lines, which are absent from supernovae originating from the collapse of massive stars. Silicon is one of the products that results from the fusion of carbon and oxygen, which bears out the scenario we described above—that there is a sudden onset of the fusion of the carbon (and oxygen) of which the white dwarf was made.
Observational evidence now strongly indicates that SN 1006 , Tycho’s Supernova , and Kepler’s Supernova (see Supernovae in History) were all type Ia supernovae. For instance, in contrast to the case of SN 1054 , which yielded the spinning pulsar in the Crab Nebula, none of these historical supernovae shows any evidence of stellar remnants that have survived their explosions. Perhaps even more puzzling is that, so far, astronomers have not been able to identify the companion star feeding the white dwarf in any of these historical supernovae.
Consequently, in order to address the mystery of the absent companion stars and other outstanding puzzles, astronomers have recently begun to investigate alternative mechanisms of generating type Ia supernovae. All proposed mechanisms rely upon white dwarfs composed of carbon and oxygen, which are needed to meet the observed absence of hydrogen in the type Ia spectrum. And because any isolated white dwarf below the Chandrasekhar mass is stable, all proposed mechanisms invoke a binary companion to explode the white dwarf. The leading alternative mechanism scientists believe creates a type Ia supernova is the merger of two white dwarf stars in a binary system. The two white dwarfs may have unstable orbits, such that over time, they would slowly move closer together until they merge. If their combined mass is greater than the Chandrasekhar limit, the result could also be a type Ia supernova explosion.
You can watch a short video about Supernova SN 2014J, a type Ia supernova discovered in the Messier 82 (M82) galaxy on January 21, 2014, as well as see brief animations of the two mechanisms by which such a supernova could form.
Type Ia supernovae are of great interest to astronomers in other areas of research. This type of supernova is brighter than supernovae produced by the collapse of a massive star. Thus, type Ia supernova e can be seen at very large distances, and they are found in all types of galaxies. The energy output from most type Ia supernovae is consistent, with little variation in their maximum luminosities, or in how their light output initially increases and then slowly decreases over time. These properties make type Ia supernovae extremely valuable “standard bulbs” for astronomers looking out at great distances—well beyond the limits of our own Galaxy. You’ll learn more about their use in measuring distances to other galaxies in The Big Bang.
In contrast, type II supernovae are about 5 times less luminous than type Ia supernovae and are only seen in galaxies that have recent, massive star formation. Type II supernovae are also less consistent in their energy output during the explosion and can have a range a peak luminosity values.
Neutron Stars with Companions
Now let’s look at an even-more mismatched pair of stars in action. It is possible that, under the right circumstances, a binary system can even survive the explosion of one of its members as a type II supernova . In that case, an ordinary star can eventually share a system with a neutron star . If material is then transferred from the “living” star to its “dead” (and highly compressed) companion, this material will be pulled in by the strong gravity of the neutron star. Such infalling gas will be compressed and heated to incredible temperatures. It will quickly become so hot that it will experience an explosive burst of fusion. The energies involved are so great that we would expect much of the radiation from the burst to emerge as X-rays. And indeed, high-energy observatories above Earth’s atmosphere (see Astronomical Instruments) have recorded many objects that undergo just these types of X-ray bursts .
If the neutron star and its companion are positioned the right way, a significant amount of material can be transferred to the neutron star and can set it spinning faster (as spin energy is also transferred). The radius of the neutron star would also decrease as more mass was added. Astronomers have found pulsars in binary systems that are spinning at a rate of more than 500 times per second! (These are sometimes called millisecond pulsars since the pulses are separated by a few thousandths of a second.)
Such a rapid spin could not have come from the birth of the neutron star; it must have been externally caused. (Recall that the Crab Nebula pulsar, one of the youngest pulsars known, was spinning “only” 30 times per second.) Indeed, some of the fast pulsars are observed to be part of binary systems, while others may be alone only because they have “fully consumed” their former partner stars through the mass transfer process. (These have sometimes been called “ black widow pulsar s.”)
View this short video to see Dr. Scott Ransom, of the National Radio Astronomy Observatory, explain how millisecond pulsars come about, with some nice animations.
And if you thought that a neutron star interacting with a “normal” star was unusual, there are also binary systems that consist of two neutron stars. One such system has the stars in very close orbits to one another, so much that they continually alter each other’s orbit. Another binary neutron star system includes two pulsars that are orbiting each other every 2 hours and 25 minutes. As we discussed earlier, pulsars radiate away their energy, and these two pulsars are slowly moving toward one another, such that in about 85 million years, they will actually merge (see Gravitational Wave Astronomy for our first observations of such a merger).
We have now reached the end of our description of the final stages of stars, yet one piece of the story remains to be filled in. We saw that stars whose core masses are less than 1.4 M Sun at the time they run out of fuel end their lives as white dwarfs. Dying stars with core masses between 1.4 and about 3 M Sun become neutron stars. But there are stars whose core masses are greater than 3 M Sun when they exhaust their fuel supplies. What becomes of them? The truly bizarre result of the death of such massive stellar cores (called a black hole ) is the subject of our next chapter. But first, we will look at an astronomical mystery that turned out to be related to the deaths of stars and was solved through clever sleuthing and a combination of observation and theory.
Footnotes
- 3 We now know that this historical terminology is quite misleading since novae do not originate from new stars. In fact, quite to the contrary, novae originate from white dwarfs, which are actually the endpoint of stellar evolution for low-mass stars. But since the system of two stars was too faint to be visible to the naked eye, it did seem to people, before telescopes were invented, that a star had appeared where nothing had been visible.


12.5A: Minimal Inhibitory Concentration (MIC)
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Learning Objectives
- Analyze data to interpret minimal inhibitory concentration values
Definition and Measurement
In microbiology, minimum inhibitory concentration (MIC) is the lowest concentration of an antimicrobial (like an antifungal, antibiotic or bacteriostatic) drug that will inhibit the visible growth of a microorganism after overnight incubation. MICs can be determined on plates of solid growth medium (called agar, shown in the “Kirby-Bauer Disk Susceptibility Test” atom) or broth dilution methods (in liquid growth media, shown in ) after a pure culture is isolated. For example, to identify the MIC via broth dilution, identical doses of bacteria are cultured in wells of liquid media containing progressively lower concentrations of the drug. The minimum inhibitory concentration of the antibiotic is between the concentrations of the last well in which no bacteria grew and the next lower dose, which allowed bacterial growth. There are also several commercial methods available to experimentally measure MIC values.
Significance and Applications
An MIC is generally regarded as the most basic laboratory measurement of the activity of an antimicrobial agent against an organism. Because a lower MIC value indicates that less of the drug is required in order to inhibit growth of the organism, drugs with lower MIC scores are more effective antimicrobial agents. Currently, there are a few web-based, freely accessible MIC databases. MIC scores are important in diagnostic laboratories to confirm resistance of microorganisms to an antimicrobial agent and also to monitor the activity of new antimicrobial agents. Clinicians use MIC scores to choose which antibiotics to administer to patients with specific infections and to identify an effective dose of antibiotic. This is important because populations of bacteria exposed to an insufficient concentration of a particular drug or to a broad-spectrum antibiotic (one designed to inhibit many strains of bacteria) can evolve resistance to these drugs. Therefore, MIC scores aid in improving outcomes for patients and preventing evolution of drug-resistant microbial strains.
Key Points
- Minimum inhibitory concentration (MIC) can be determined by culturing microorganisms in liquid media or on plates of solid growth medium.
- A lower MIC value indicates that less drug is required for inhibiting growth of the organism; therefore, drugs with lower MIC scores are more effective antimicrobial agents.
- By identifying appropriate drugs and their effective concentrations, MIC scores aid in improving outcomes for patients and preventing evolution of drug-resistant microbial strains.
Key Terms
- culture : The process of growing a bacterial or other biological entity in an artificial medium.
- minimum inhibitory concentration : This is the lowest concentration of an antimicrobial drug that prevents visible growth of a microorganism after overnight incubation with media.
- bacteriostatic : A drug that prevents bacterial growth and reproduction but does not necessarily kill them. When it is removed from the environment the bacteria start growing again.


11.A: Review Questions
Complete as directed.
Fill in the Blanks:
- Employees working along, at, above or near wall openings where the outside bottom edge of the wall openings is feet or more above lower levels must have fall protection provided.
- The Fall Protection Standard sets up a uniform threshold of ________ feet for determining when fall protection is required.
- The top height of the guardrail shall be ________ inches, plus or as a minus 3 inches.
- Safety net systems must be installed as close as practical to the working surface and in no case more than ________ feet below such level.
- Where no mechanical equipment is being used, warning lines must be located at least ________ feet from the roof edge.
- Guardrails must be capable the standing a ________ pound downward force applied within ________ inches of the top rail at any point along the top edge.
- Covers for floor openings must be marked with the word ________ or ________ or shall be color-coded to provide warning of the hazard.
- The attachment point for a body harness, used for fall protection, shall be located where?
True or False: (Circle the Correct Answer)
- Several types of activities covered by the standard can be performed without fall protection provided the employer can demonstrate the fall protection is infeasible or creates a great hazard by its use. T or F
- If no other fall protection system has been implemented the employer must have a safety monitoring system. T of F


1.14: Social Media
- Describe strategies for effective, safe, and professional social media use in college
Social Media
While it used to be that social media was the distraction from homework, now, your professors are finding ways to incorporate social media into your classes. Professors may require students to make Facebook posts or Tweet about certain topics related to a course, and, some courses even have their own Facebook pages.
While most of us have some experience with social media, our use of social media for personal purposes may be very different from the uses of social media in an academic or professional setting. Consider the purpose of your assignment and the specifics of your audience when using social media for schoolwork. Below are a few best practices for using Twitter.
Twitter is a social networking tool that allows individuals to send short text messages known as tweets. Tweets originally began by maxing out at 140 characters; now tweets up to 280 characters are permitted.
Writing Tweets: The Basics
Keep your tweets:
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Short
280 characters maximum. Twitter counts down from 280, and lets you know how many characters you have left to use once you start getting close. -
And Even Shorter
If you want others to forward your tweet (re-tweet), you may want to use fewer than 280 characters. Remember that Twitter provides a stream of short updates for those people, organizations, or issues you want to follow, and gaining a following (via re-tweets) is often a goal of those who use Twitter. On average, try to reserve at least 20 characters so your message can be re-tweeted. -
Meaningful
Pare down the information to keywords, and put what you consider to be the most important information first. Phrases will suffice. While there is no need to use complete sentences or formal writing practices, try to write with care. Sloppy, error-filled tweets don’t give your Tweets credibility.
Here are some additional tips to keep in mind as you give tweeting a try:
- Use the hashtag symbol (#) without a space before the word or words you want to emphasize and make more searchable . If you’re emphasizing more than one word, also put those words together without spaces. For example, if you want to emphasize a statement that you’re making about grade schools banning soda, you might do it in this way:
- Incorporate links in your tweets as a way to offer more information than that allowed by the 280-character limit . You might link to your website, blog, or any other meaningful or appropriate site.
- Remember that the image you insert into your profile appears by each of your tweets . If you have an interesting image, readers’ eyes will gravitate toward your tweet.
- You can comment on others’ tweets . To respond to (or tag) another person’s tweet, use the @ sign and the person’s name without any spaces. Replies using the @ sign are public on Twitter. For example, if you wanted to respond publicly to John Smith’s tweet, you might start your tweet in this way: @JohnSmith. You can place an @ reply anywhere in the tweet—it doesn’t necessarily have to be at the start. The response you send to John Smith using the @ sign will appear on your Profile page and on John Smith’s @Mentions space.
Your Digital Footprint
Your digital footprint is the path you leave on the web. When people, including potential employers, search your name on the web, what will they find? It’s a good idea to have a digital footprint, to put your resume and a collection of your work on the web. There are many opportunities for you to share your writing on the web. Today, we have forums for sharing essays, videos, work history, and pictures of our children. This provides us with a wonderful opportunity to share our creativity with the world. However, it’s important to be mindful of your goals when you share on the web and to remember that information you put on the web is there for anyone to see and will remain there even after you may forget what you posted.
Digital Safety and Security
You want to be careful about the kind of information you share. Remember, potential employers can search for you on Facebook, and if you post your phone number on the web for anyone to see, you might receive unwanted phone calls. Be careful about revealing personal information that might compromise your digital security.
As you create things like Facebook and Twitter accounts and web pages for your writing, think about what you want your digital footprint to be like. What will potential employers find when they search for more information about you? Do you want to make your information more secure? Social media accounts give you privacy options, and websites give you security options related to who can see your site.
Contributors and Attributions
- Modification, adaptation, and original content. Provided by : Lumen Learning. License : CC BY: Attribution
- Online Writing and Presentations. Provided by : Excelsior Online Reading Lab. Located at : https://owl.excelsior.edu/online-writing-and-presentations/ . License : CC BY: Attribution


7.3: Persecution
Persecution involves the indiscriminate abuse or killing of a group of animals, generally used as a strategy to prevent property damage (e.g. crop-raiding elephants) and livestock depredation (e.g. lions endangering cattle). Some animals are also persecuted because of the real or perceived dangers they pose to humans; this includes the indiscriminate killing of sharks, snakes, and spiders to avoid bites, and culling of bats to prevent spread of zoonotic diseases (Schneeberger and Voigt, 2016). Lastly, local folklore also contributes to persecution: animals, such as moles, chameleons, and owls are sometimes indiscriminately killed because of cultural beliefs that they bring bad luck.
While killing a (potential or perceived) problem animal may bring a certain instant gratification, it is a short-term solution that often causes more harm than good.
While killing a (potential or perceived) problem animal may bring a certain instant gratification, it is a short-term solution that often causes more harm than good. Culling bats, for example, may in fact increase the prevalence of the same zoonotic diseases people are trying to control (Schneeberger and Voigt, 2016). Persecution also leads to the loss of ecosystem services, as it often targets ecosystem engineers and keystone species (Section 4.2.1). Retaliatory poisoning is particularly harmful for all the other useful organisms that may be killed in the process. One study in Namibia estimated that about 100 non-target animals are killed for every target animal, putting harmless species such as aardwolf (Proteles cristatus, LC), bat-eared fox (Otocyon megalotis, LC), and Cape fox (Vulpes chama, LC) also at risk (Brown, 2006). Among the most vulnerable to such poisoning are vultures, which may be accidentally poisoned by bait set out for problem predators, or directly targeted for traditional medicine and to hide poaching activities. In June 2019, 537 vultures (comprising five different Endangered and Critically Endangered species) were killed in Botswana after scavenging from three poisoned elephant carcass (de Greef, 2019). This mass poisoning event was particularly devastating because it was during the vulture breeding season, so many vulture chicks likely also died from starvation if not from eating tainted meat brought back to the nest by their parents.


6.2.2: Introduction
The pH of an environment can affect the growth and survival of the microbes in that environment. pH is a measure of the hydrogen ion concentration or activity, in a solution, expressed as:
\[-\log_{10}[H+] \nonumber \]
Every organism has an optimal pH range at which it will grow. If the pH is too high or too low it can affect things like the solubility of molecules, denaturation of proteins/enzymes, membrane transport, proton-motive force/membrane potential, etc. These changes can be devastating to a bacterial population. We have exploited this in the production of foods, for example, pickling is a common method of food preservation and compounds like citric acid are often added to food products to lower the pH and prevent spoilage or toxin formation.
Most bacteria are neutrophils while fungi prefer a more acidic environment from pH 4-6. Archaea are found in all ranges. Nonetheless, all microbes keep their internal environment near neutral and some have developed mechanisms to allow them to survive in the more extreme ranges.
In microbiology we also use a variety of biochemical tests based on pH changes in the media as diagnostic tests. Many bacteria produce acids that are released into the environment as metabolic products of fermentation. These acids can have a big effect on the pH of a closed system like a test tube or agar plate. You will utilize some of these biochemical tests in the future to help you identify bacteria and key characteristics of them.
The pH scale is a tool to measure the relative acidity of solutions, food, natural environments like lakes (water), and as stated, biochemical reactions. The scale is logarithmic reflecting the definition of pH and actually making the scale easy to use. pH 0, which is the most acidic level, has a hydrogen ion concentration of 100 moles/L; pH 14, the most alkaline, has a hydrogen ion concentration of 10-14 moles/L. Pure water is neutral and therefore has a pH of 7 (10-7 moles/L). Each pH level represents then a tenfold decrease or increase in hydrogen ion concentration. So, pH6 is ten times more acidic than pH 7, and ten times more alkaline than pH 5.
There are 3 main groups of microbes classified by the pH range they can survive in:
Acidophiles: pH 0-5.5
Neutrophiles: pH 5.5-8.0
Alkaliphiles: pH 8.0-11.5


15.10: Dissociative Disorders
Learning Objectives
- Describe the essential nature of dissociative disorders
- Identify and differentiate the symptoms of dissociative amnesia, depersonalization/ derealization disorder, and dissociative identity disorder
- Discuss the potential role of both social and psychological factors in dissociative identity disorder
Dissociative disorders are characterized by an individual becoming split off, or dissociated, from her core sense of self. Memory and identity become disturbed; these disturbances have a psychological rather than physical cause. Dissociative disorders listed in the DSM-5 include dissociative amnesia, depersonalization/derealization disorder, and dissociative identity disorder.
Dissociative Amnesia
Amnesia refers to the partial or total forgetting of some experience or event. An individual with dissociative amnesia is unable to recall important personal information, usually following an extremely stressful or traumatic experience such as combat, natural disasters, or being the victim of violence. The memory impairments are not caused by ordinary forgetting. Some individuals with dissociative amnesia will also experience dissociative fugue (from the word “to flee” in French), whereby they suddenly wander away from their home, experience confusion about their identity, and sometimes even adopt a new identity (Cardeña & Gleaves, 2006). Most fugue episodes last only a few hours or days, but some can last longer. One study of residents in communities in upstate New York reported that about 1.8% experienced dissociative amnesia in the previous year (Johnson, Cohen, Kasen, & Brook, 2006).
Some have questioned the validity of dissociative amnesia (Pope, Hudson, Bodkin, & Oliva, 1998); it has even been characterized as a “piece of psychiatric folklore devoid of convincing empirical support” (McNally, 2003, p. 275). Notably, scientific publications regarding dissociative amnesia rose during the 1980s and reached a peak in the mid-1990s, followed by an equally sharp decline by 2003; in fact, only 13 cases of individuals with dissociative amnesia worldwide could be found in the literature that same year (Pope, Barry, Bodkin, & Hudson, 2006). Further, no description of individuals showing dissociative amnesia following a trauma exists in any fictional or nonfictional work prior to 1800 (Pope, Poliakoff, Parker, Boynes, & Hudson, 2006). However, a study of 82 individuals who enrolled for treatment at a psychiatric outpatient hospital found that nearly \(10\%\) met the criteria for dissociative amnesia, perhaps suggesting that the condition is underdiagnosed, especially in psychiatric populations (Foote, Smolin, Kaplan, Legatt, & Lipschitz, 2006).
Depersonalization/ Derealization Disorder
Depersonalization/derealization disorder is characterized by recurring episodes of depersonalization, derealization, or both. Depersonalization is defined as feelings of “unreality or detachment from, or unfamiliarity with, one’s whole self or from aspects of the self” (APA, 2013, p. 302). Individuals who experience depersonalization might believe their thoughts and feelings are not their own; they may feel robotic as though they lack control over their movements and speech; they may experience a distorted sense of time and, in extreme cases, they may sense an “out-of-body” experience in which they see themselves from the vantage point of another person. Derealization is conceptualized as a sense of “unreality or detachment from, or unfamiliarity with, the world, be it individuals, inanimate objects, or all surroundings” (APA, 2013, p. 303). A person who experiences derealization might feel as though he is in a fog or a dream, or that the surrounding world is somehow artificial and unreal. Individuals with depersonalization/derealization disorder often have difficulty describing their symptoms and may think they are going crazy (APA, 2013).
Dissociative Identity Disorder
By far, the most well-known dissociative disorder is dissociative identity disorder (formerly called multiple personality disorder). People with dissociative identity disorder exhibit two or more separate personalities or identities, each well-defined and distinct from one another. They also experience memory gaps for the time during which another identity is in charge (e.g., one might find unfamiliar items in her shopping bags or among her possessions), and in some cases may report hearing voices, such as a child’s voice or the sound of somebody crying (APA, 2013). The study of upstate New York residents mentioned above (Johnson et al., 2006) reported that \(1.5\%\) of their sample experienced symptoms consistent with dissociative identity disorder in the previous year.
Dissociative identity disorder (DID) is highly controversial. Some believe that people fake symptoms to avoid the consequences of illegal actions (e.g., “I am not responsible for shoplifting because it was my other personality”). In fact, it has been demonstrated that people are generally skilled at adopting the role of a person with different personalities when they believe it might be advantageous to do so. As an example, Kenneth Bianchi was an infamous serial killer who, along with his cousin, murdered over a dozen females around Los Angeles in the late 1970s. Eventually, he and his cousin were apprehended. At Bianchi’s trial, he pled not guilty by reason of insanity, presenting himself as though he had DID and claiming that a different personality (“Steve Walker”) committed the murders. When these claims were scrutinized, he admitted faking the symptoms and was found guilty (Schwartz, 1981).
A second reason DID is controversial is because rates of the disorder suddenly skyrocketed in the 1980s. More cases of DID were identified during the five years prior to 1986 than in the preceding two centuries (Putnam, Guroff, Silberman, Barban, & Post, 1986). Although this increase may be due to the development of more sophisticated diagnostic techniques, it is also possible that the popularization of DID—helped in part by Sybil , a popular 1970s book (and later film) about a woman with \(16\) different personalities—may have prompted clinicians to overdiagnose the disorder (Piper & Merskey, 2004). Casting further scrutiny on the existence of multiple personalities or identities is the recent suggestion that the story of Sybil was largely fabricated, and the idea for the book might have been exaggerated (Nathan, 2011).
Despite its controversial nature, DID is clearly a legitimate and serious disorder, and although some people may fake symptoms, others suffer their entire lives with it. People with this disorder tend to report a history of childhood trauma, some cases having been corroborated through medical or legal records (Cardeña & Gleaves, 2006). Research by Ross et al. (1990) suggests that in one study about \(95\%\) of people with DID were physically and/or sexually abused as children. Of course, not all reports of childhood abuse can be expected to be valid or accurate. However, there is strong evidence that traumatic experiences can cause people to experience states of dissociation, suggesting that dissociative states—including the adoption of multiple personalities—may serve as a psychologically important coping mechanism for threat and danger (Dalenberg et al., 2012).
Summary
The main characteristic of dissociative disorders is that people become dissociated from their sense of self, resulting in memory and identity disturbances. Dissociative disorders listed in the DSM-5 include dissociative amnesia, depersonalization/derealization disorder, and dissociative identity disorder. A person with dissociative amnesia is unable to recall important personal information, often after a stressful or traumatic experience.
Depersonalization/derealization disorder is characterized by recurring episodes of depersonalization (i.e., detachment from or unfamiliarity with the self) and/or derealization (i.e., detachment from or unfamiliarity with the world). A person with dissociative identity disorder exhibits two or more well-defined and distinct personalities or identities, as well as memory gaps for the time during which another identity was present.
Dissociative identity disorder has generated controversy, mainly because some believe its symptoms can be faked by patients if presenting its symptoms somehow benefits the patient in avoiding negative consequences or taking responsibility for one’s actions. The diagnostic rates of this disorder have increased dramatically following its portrayal in popular culture. However, many people legitimately suffer over the course of a lifetime with this disorder.
Glossary
- depersonalization/derealization disorder
- dissociative disorder in which people feel detached from the self (depersonalization), and the world feels artificial and unreal (derealization)
- dissociative amnesia
- dissociative disorder characterized by an inability to recall important personal information, usually following an extremely stressful or traumatic experience
- dissociative disorders
- group of DSM-5 disorders in which the primary feature is that a person becomes dissociated, or split off, from his or her core sense of self, resulting in disturbances in identity and memory
- dissociative fugue
- symptom of dissociative amnesia in which a person suddenly wanders away from one’s home and experiences confusion about his or her identity
- dissociative identity disorder
- dissociative disorder (formerly known as multiple personality disorder) in which a person exhibits two or more distinct, well-defined personalities or identities and experiences memory gaps for the time during which another identity emerged
Contributors and Attributions
-
Rose M. Spielman with many significant contributors. The OpenStax name, OpenStax logo, OpenStax book covers, OpenStax CNX name, and OpenStax CNX logo are not subject to the creative commons license and may not be reproduced without the prior and express written consent of Rice University. For questions regarding this license, please contact<EMAIL_ADDRESS>.Textbook content produced by OpenStax College is licensed under a Creative Commons Attribution License 4.0 license. Download for free at<EMAIL_ADDRESS>.


6.6: Syncretism and Exclusivism
Syncretism
Syncretism is the process by which elements of one religion are assimilated into another religion, resulting in a change in the fundamental beliefs of those religions. This change does not always result in a total fusion of the religions but bits and pieces that one religion has adopted from another. In some cases, deities or influential figures are blended and called by one name but retain attributes, images, symbols and sometimes holy sites from the original religions.
An ethnographic example of syncretism is The Virgin of Guadalupe appearing to Juan Diego, a Nahuati speaking man, at Tepeyac hill near Mexico City. This was the site of the temple or the Aztec mother goddess Tohantizin. Mary requested a church be built on that site. When Juan Diego visited the Bishop and told him what Mary had said, the Bishop requested a sign that Juan Diego was telling the truth. Juan Diego returned to the hill where Mary told him to collect roses and bring them to the Bishop. When he returned to the bishop with roses in his timla, he dropped the roses at the feet of the Bishop, and on the tilma appeared the image of the Virgin of Guadalupe. This merged the pre-Christian goddess Tohantizin with the Catholic saint the Virgin of Guadalupe, creating a way through which the local people could practice their faith through a Catholic conduit.
Exclusivism
Exclusivism is the view that one's own religion is inerrant and all others are in error. Exclusivism may also relate to practice, as in the way the gods, dietys, etc. are revered, rather than mere belief.
An example of exclusivism is the Ancient Greek Religion, which combined many local deities, such as nymphs and other divinities connected to nature, into the myth system of the Greek Pantheon. The Decree of Diopithes of 430BCE forbade the worship or introduction of and the belief in deities other than the Greek Pantheon and made it an offense punishable by death.
Another form of exclusivity can be seen through Christianity, by way that they do not promote syncretism, but instead contextualization. 21 st Century Christians consider syncretism as a Christian exhibiting actions that do not reflect Christian beliefs, yet proclaim themselves as such. Christians discourage syncretism because Christians are supposed to live out their beliefs and lead a life that confirms their belief. Contextualization is when Christians associate with non-believers yet exhibit their beliefs, which is encouraged in place of syncretism.
In its more extreme form, religious exclusivism teaches that only the members of one religion or sect will reach Heaven, while others will be doomed to eternal damnation. In the past there was the saying in relation to the belief in God that was often used saying 'if you don't believe in God you will go to hell'. The opposite of religious exclusivism is universalism, the teaching that all will eventually share in the eternal blessings of God or the heavenly realm.


18.4: Management of Impaired Cardiopulmonary Functioning
By the end of this section, you will be able to:
- Describe nursing actions for management of impaired cardiopulmonary functioning
- Understand interdisciplinary collaboration for management of impaired cardiopulmonary functioning
- Describe emergency interventions for impaired cardiopulmonary functioning
Nurses are involved in the management of cardiopulmonary care throughout the care plan, from assessment and planning through evaluation and reassessment. Nursing actions while caring for patients with impaired cardiopulmonary function are varied, from routine to emergent care. Patients with cardiovascular and/or pulmonary dysfunctions may be stable or suffering an emergency event, such as a deadly cardiac rhythm or a respiratory or cardiac arrest. Depending on the care setting, nurses have to be able to respond and act to patients’ changes in status, with interventions, patient education, and guidance regarding self-monitoring, through drug therapy (routine and emergent), defibrillation, and CPR. Nurses are also part of a healthcare team and as such work with other members from different disciplines. Interdisciplinary care provides a holistic approach to patients and their care and brings about positive outcomes.
Nursing Actions
Nurses are directly involved in patient care. From assessment to evaluation, nurses are creating, implementing, and evaluating their care plans based on the current status of their patients. Nursing actions relative to the cardiopulmonary system reflect particular actions designed for the respiratory system and those for the cardiovascular system. Some interventions, like O 2 therapy and behavioral modifications, are apt to benefit both components of the cardiopulmonary system. Even drug therapy in one category is prone to assist with symptoms or deficits in the other, as an improvement in ventilation , oxygenation, or perfusion can be expected to improve the others. In this section, specifics as to assessment, a variety of tools and techniques, medications, and topics for patient education are discussed. Additionally, interdisciplinary collaborative examples are explored as are emergency interventions specific to the respiratory and cardiovascular systems.
Respiratory Assessment
The evaluation of the respiratory system includes collecting subjective and objective data through a detailed interview and physical examination of the thorax and lungs. This examination can offer significant clues related to issues associated with the body’s ability to obtain adequate oxygen to perform daily functions. Inadequacy in respiratory function can have significant implications for the overall health of the patient.
Collect subjective data using interview questions, paying particular attention to what the patient is reporting. The interview should include questions regarding any current and past history of respiratory health conditions or illnesses, medications, and reported symptoms. Consider the patient’s age, gender, family history, race, culture, environmental factors, and current health practices when gathering subjective data.
A focused respiratory objective assessment includes interpretation of vital sign s; inspection of the patient’s breathing pattern, skin color, and respiratory status; palpation to identify abnormalities; and auscultation of lung sounds (Figure 18.24) using a stethoscope. The nurse must have an understanding of what is expected given a patient’s age, gender, development, race, culture, environmental factors, and current health condition to determine the meaning of the data that are being collected.
When certain findings indicate further exploration, palpation and percussion may be performed. An example is if on inspection the nurse finds apparent edema around one or both collarbones, especially if the patient was recently intubated with an ETT. Palpation can be used in such a situation to assess for subcutaneous emphysema (air in the subcutaneous tissue), as the tiny air pockets feel crispy ( crepitus ) to the fingertips. Percussion is helpful for the nurse to determine underlying structures in the pulmonary cavity, whether a region that should be air filled instead contains fluid or a solid mass. Refer to Table 18.4 for expected and unexpected assessment results.
| Assessment | Expected Findings | Unexpected Findings (Document and Notify Provider if a New Finding*) |
|---|---|---|
| Inspection |
|
|
| Palpation |
|
|
| Percussion |
|
|
| Auscultation |
|
|
|
*CRITICAL CONDITIONS
to report immediately |
|
Cardiovascular Assessment
The evaluation of the cardiovascular system includes a thorough medical history and a detailed examination of the heart and peripheral vascular system. Nurses must incorporate subjective statements and objective findings to elicit clues of potential signs of dysfunction. Symptoms like fatigue, indigestion, and leg swelling may be benign or may indicate something more ominous. As a result, nurses must be vigilant when collecting comprehensive information to utilize their best clinical judgment when providing care for the patient.
The subjective assessment of the cardiovascular and peripheral vascular system is vital for uncovering signs of potential dysfunction. To complete the subjective cardiovascular assessment, the nurse begins with a focused interview. The focused interview explores past medical and family history, medications, cardiac risk factors, and reported symptoms. Symptoms related to the cardiovascular system include chest pain, peripheral edema, unexplained sudden weight gain, shortness of breath (dyspnea), irregular pulse rate or rhythm, dizziness, or poor peripheral circulation. Any new or worsening symptoms should be documented and reported to the healthcare provider.
The physical examination of the cardiovascular system involves the interpretation of vital sign s, inspection, palpation, and auscultation of heart sounds. Jugular venous distension may be visible, especially as patients are repositioned. As the nurse is examining the patient, palpation may accompany, as clothing is moved or removed and the patient is touched. Further signs of perfusion can be assessed, like the temperature and moisture of the skin (e.g., warm and dry versus cool and clammy). To complete palpation, capillary refill and peripheral pulses should be assessed. After completing a cardiovascular assessment, it is important for the nurse to use critical thinking to determine whether any findings require follow-up (Table 18.5).
| Assessment | Expected Findings | Unexpected Findings (Document and Notify Provider if a New Finding*) |
|---|---|---|
| Inspection | Apical impulse may or may not be visible |
|
| Palpation | Apical pulse felt over midclavicular fifth intercostal space |
|
| Auscultation | S1 and S2 heart sounds in regular rhythm |
|
|
*CRITICAL CONDITIONS
to report immediately |
|
Auscultation is routinely performed over five specific areas of the heart to listen for corresponding valvular sounds. These auscultation sites are often referred to by the mnemonic “APE To Man,” referring to aortic, pulmonic, Erb point, tricuspid, and mitral areas (Figure 18.25).
Auscultation usually begins at the aortic area (upper right sternal edge). Use the diaphragm of the stethoscope to carefully identify the S1 and S2 sounds. They will make a “lub-dub” sound. Note that when listening over the area of the aortic and pulmonic valves, the “dub” (S2) will sound louder than the “lub” (S2). Move the stethoscope sequentially to the pulmonic area, Erb point, and tricuspid area. Repeat this process with the bell of the stethoscope. The apical pulse should be counted over a sixty-second period. For an adult, the HR should be between 60 and 100 with a regular rhythm to be considered within normal range.
A review of blood flow and the heart’s sounds is provided in this video. Listen for normal and abnormal sounds and what they mean.
The first heart sound (S1) identifies the onset of systole, and the second heart sound (S2) identifies the end of systole and the onset of diastole; when the semilunar valves close, the AV valves open, and the ventricles fill with blood. When auscultating, it is important to identify the S1 (“lub”) and S2 (“dub”) sounds, evaluate the rate and rhythm of the heart, and listen for any extra heart sounds.
Encourage Breathing Techniques
There are several techniques a nurse can teach a patient to use to enhance their breathing and coughing. These techniques include diaphragmatic breathing, pursed-lip breathing, incentive spirometry , and coughing and deep breathing.
Diaphragmatic Breathing
Diaphragmatic breathing is a technique that is helpful for patients who are tachypneic, whether from a physiological source or anxiety. The technique helps focus attention on breathing and consciously learn to control it. The nurse teaches the patient to intentionally realize whether the chest or the abdomen is the source of breaths. It is often recommended to advise the patient to place a hand on the chest and one on the abdomen and self-assess the source. This begins the slowing and relaxing process. Once the patient realizes the source of breath is the chest, teaching is aimed at the patient redirecting attention toward breathing from the abdomen (diaphragm). With concentration on the technique, the tachypnea should begin to resolve, and with it, an improvement as the physical response to pH changes from hyperventilation normalizes and/or a sense of relaxation and anxiety reduction takes place. Sometimes the anxiety involved with severe dyspnea , or from a mental health situation, may respond well to anxiolytic drug therapy in addition to diaphragmatic breathing.
Pursed-Lip Breathing
Pursed-lip breathing is a technique that allows people to control their oxygenation and ventilation . The technique requires a person to inspire through the nose and exhale through the mouth at a slow, controlled flow. This type of exhalation gives the person a puckered or pursed appearance. By prolonging the expiratory phase of respiration , a small amount of positive end-expiratory pressure is created in the airways that helps to keep them open so that more air can be exhaled, thus reducing air trapping that occurs in some conditions such as COPD. Pursed-lip breathing often relieves the feeling of shortness of breath, decreases the work of breathing, and improves gas exchange . People also regain a sense of control over their breathing while simultaneously increasing their relaxation.
Incentive Spirometry
An incentive spirometer is a medical device often prescribed after surgery to prevent and treat atelectasis (Figure 18.6). Atelectasis occurs when alveoli become deflated or filled with fluid, and this can lead to pneumonia. While sitting upright, the patient should breathe in slowly and deeply through the tubing with the goal of raising the piston to a specified level. The patient should attempt to hold their breath for five seconds, or as long as tolerated, and then rest for a few seconds. This technique should be repeated by the patient ten times every hour while awake. The nurse may delegate this intervention to unlicensed assistive personnel, but the frequency at which it is completed and the volume achieved should be documented and monitored by the nurse.
Coughing and Deep Breathing
Teaching the coughing and deep breathing technique is similar to incentive spirometry , but no device is required. The patient is encouraged to take deep, slow breaths and then exhale slowly. After each set of breaths, the patient should cough. This technique is repeated three to five times every hour.
Nurse:
Aarti, RN
Clinical setting:
ICU
Years in practice:
2
Facility location:
San Jose, California
My patient assignment for the night was a male (Mr. Leonard, or Mr. L) who had undergone coronary artery bypass grafting (CABG) earlier in the day. His surgery had gone well, with no major events during or in the first few hours of recovery in the ICU. As we did shift report, and bedside check, hemodynamics were stable, and Mr. L’s major issue was pain. I brought a syringe of morphine with me when I did his initial assessment and gave him his first divided dose. By the time I was done with a head-to-toe at 7:30 p.m., he was gently snoring.
The standard for ICU patients was for them to be turned at least every two hours; post-op CABG patients hourly, to keep pulmonary secretions mobile, and the chest tubes draining. The IS orders were for “ten times while awake,” but Mr. L had refused the previous hour with the day shift nurse, and now he was asleep. I let him rest at 7:30 p.m., and since he was still sleeping at 8 p.m., didn’t wake him. His VS continued to be fine, and while I turned him at 9 p.m., I didn’t insist he do his ten reps of the IS. When I checked his VS at 10 p.m., all was stable except his temperature of 100.6°F (38°C); I medicated his 8-of-10 pain and went to the nurses’ station to review the flowchart and chart—his temperature had been 97.8°F (36.6°C) at 7:30 p.m. One of my colleagues asked how Mr. L was doing, and I told her about the low-grade fever. Her first question was, “How has he been doing on his IS?” Surprised, I admitted that I hadn’t had him do it, as I was focused on his pain control and rest. But her question clicked that subject open in my mind, and I began consistent pulmonary toilet—while he was not happy to be kept awake, he did the breathing exercises as I requested. An hour later, I medicated his pain, and a few minutes later insisted on the IS again.
At midnight, I checked his temperature again, fully expecting it to have climbed further, but it was 98.9°F (37.2°C). At that moment, early in my practice, I became fully convinced of the power of aggressive pulmonary toilet and the ability of deep breathing to reduce and prevent atelectasis . Mr. L and I continued with his hourly IS throughout the early morning hours, and his temp was 98.3°F (36.8°C) at 4 a.m. As I drove home and reflected on the events of the shift, I thought about how easy it is for a patient to develop atelectasis, and the importance of early prevention through deep breathing and coughing. The other realization for me was how easy it probably would have been for me to prevent it entirely by starting the IS with my first shift assessment. However, by having had this experience (and happily with Mr. L’s quick recovery from all aspects of his surgery, without development of post-op pneumonia!), my patient education on the rationale for use of the IS from that night forward became much more compelling.
Frequent Repositioning
Repositioning a patient with impaired cardiopulmonary status maintains body alignment, prevents pressure injuries from low perfusion and hypoxia , and prevents foot drop and contractures. When repositioning a patient in bed, supportive devices such as pillows, rolls, and blankets can aid in providing comfort and safety. It is important to reposition patients appropriately to prevent neurological injury that can occur if a patient is inadvertently placed on their arm. Frequent repositioning also allows for respiratory secretions to mobilize rather than pool in one location (usually dependent, based on gravity). Being turned may cause deeper breaths and may inspire coughing. Position changes also enhance comfort, which reduces pain, allowing for ease of breathing and again more likelihood of full and effective breaths.
Medication Administration
There are medications recognized as specific to the respiratory system and those associated with the cardiovascular system; some have effects on both components of the cardiopulmonary system . Medication administration for respiratory and cardiac drugs involves nurses being familiar with a variety of administration routes. Respiratory drugs may be given as nasal sprays and drops, inhalers, tablets, or capsules to be administered orally or through injections by intramuscular (IM), subcutaneous (SC), or intravenous (IV) access. Cardiac medications add the potential for topical (e.g., nitroglycerin ordered by patch or cream) application and do not include the wide variety through sprays, drops, or powders. When immediate actions are desired, drugs for cardiopulmonary emergencies are typically administered by IV or intraosseous (IO) routes, though respiratory emergencies may still require inhaled doses of certain drugs.
Respiratory Medications
There are various drug classes to treat respiratory pathophysiological problems—all with a goal relative to improving function, whether through improved oxygenation or ventilation (Table 18.6).
| Type | Drug | Mechanism of Action |
|---|---|---|
|
Sympathetic nervous system:
Beta 2 adrenergic agonists |
Albuterol (Proventil HFA) | Capitalizes on the bronchodilation response of SNS stimulation |
|
Parasympathetic nervous system:
anticholinergics |
Tiotropium (Spiriva—long acting), ipratropium (Atrovent—short acting) | Blocks the bronchoconstriction response of muscarinic PSNS stimulation |
| Methylxanthine derivatives | Theophylline (Theo-24) | Smooth muscle relaxation allowing bronchodilation |
| Corticosteroids | Triamcinolone Nasocort Allergy—nasal; Aristospan—systemic) | Prevention of reaction or worsening reaction to inflammation, whether local or systemic depends on drug, dose, and route |
| Leukotriene receptor antagonists | Montelukast (Singulair) | Blockade of leukotriene receptors and related decreased inflammatory responses |
| Cromolyn | NasalCrom | Blocks mast cells and related inflammatory actions |
| Antihistamines | Diphenhydramine (Benadryl), loratadine (Claritin) | Blocks action of histamine; first generation has broader effects, including sedation |
| Decongestants | Pseudoephedrine (Sudafed) | Adrenergic stimulation releases norepinephrine, causing vasoconstriction |
| Expectorants | Guaifenesin (Mucinex) | Causes vagal response that increases fluid in the respiratory tract; thins mucous |
| Antitussives | Dextromethorphan (Robitussin) | Depression of cough center (medulla) and cough receptors in respiratory tract |
| Anti-infectives | Numerous classes of anti-infectives—selection based on type of infection (C&S results) | Cause injury or death to infectious microbial cells |
Cardiac Medications
As varied as the potential diagnoses that affect the cardiovascular system are the drugs to treat the disorders. Medications are used to modify actions of the ANS in order to lower or raise BP; they treat dyslipidemias and often-linked CAD; antianginal drugs relieve chest pain; there are drugs to treat HF, medications to help the kidneys remove excess fluid; there are those that may treat or prevent dysrhythmias, and there are drugs to prevent and/or treat clotting problems (Table 18.7).
| Type | Drug | Mechanism of Action |
|---|---|---|
| ACE inhibitors | Lisinopril, enalapril | Vasodilation from inhibition of angiotensin-converting enzyme, and therefore prevention of angiotensin I conversion to angiotensin II (vasoconstrictor); decreases cardiac remodeling and overt HF (some patients) |
| Angiotensin receptor blockers (ARBs) | Valsartan (Diovan) | Blocks angiotensin II effects of aldosterone release and vasoconstriction at the angiotensin receptors |
| Antianginals | Nitroglycerin | Arterial and venous vasodilation increases perfusion and decreases O 2 demand |
| Anti-arrhythmic | Adenosine (Adenocard) | Temporarily slows or arrests AV conduction and return to NSR |
| Antianginals | Nitroglycerin | Arterial and venous vasodilation increases perfusion and decreases O 2 demand |
| Beta blockers | Atenolol, sotalol | Inhibits stimulation of beta receptors; prolongs cardiac cycle refractory period |
| Calcium channel blockers | Diltiazem (Cardizem) | Smooth muscle relaxation allows for vasodilation; decreases cardiac workload inhibition of calcium during depolarization |
| Cardiac glycosides | Digoxin (Lanoxin) | Improves cardiac contractility by three mechanisms: positive inotrope (increases contractility, SV, and CO), negative dromotrope (decreased cardiac conduction), and negative chronotrope (lowers HR) |
| Catecholamines | Norepinephrine | SNS stimulation causes vasoconstriction for enhanced organ perfusion |
| Diuretics (loop) | Furosemide | Inhibits reabsorption of sodium in the loop of Henle and distal tubule; increases urine and electrolyte output |
| Diuretics (potassium sparing) | Spironolactone (Aldactone) | Aldosterone antagonist—inhibits sodium reabsorption without loss of potassium |
| Diuretics (thiazide) | Hydrochlorothiazide (Microzide) | Inhibits reabsorption of sodium in the distal tubule—increases urine output |
| HMG CoA reductase inhibitors (a.k.a. “statins”) | Rosuvastatin (Crestor) | Inhibits production of cholesterol by inhibiting HMG CoA reductase; LDL is decreased |
| Neprilysin inhibitor and ARB combination | Sacubitril/valsartan (Entresto) | Inhibits neprilysin (enzyme), allowing for increased natriuretic peptides, which causes vasodilation and sodium (and water) excretion; valsartan (see ARBs) |
| Potassium channel blockers | Amiodarone (Pacerone) | Prolongs repolarization through blockade of potassium channels |
| Sodium channel blockers | Lidocaine | Decreases influx of sodium to cardiac cells—depolarization is prolonged |
Oxygen Therapy
O 2 is considered a drug and requires a prescription or healthcare provider’s order for nurses to administer it. When administering oxygen to a patient, it is important to ensure that oxygen flow rates are appropriately set according to the type of administration device (Table 18.8). When administering oxygen therapy, it is important for the nurse to assess the patient before, during, and after the procedure and document the findings.
See the competency checklist for Administering Oxygen. You can find the checklists on the Student resources tab of your book page on openstax.org.
| Device | Flow Rates and Oxygen Percentage | Image |
|---|---|---|
| Nasal cannula |
Flow rate: 1 to 6 L/min
FiO 2 : 24 to 44 percent |
|
| High-flow nasal cannula |
Flow rate: up to 60 L/min
FiO 2 : up to 100 percent |
|
| Simple mask |
Flow rate: 6 to 10 L/min
FiO 2 : 28 to 50 percent |
|
| Non-rebreather mask |
Flow rate: 10 to 15 L/min
FiO 2 : 60 to 80 percent Safety Note: The reservoir bag should always be partially inflated. |
|
| CPAP, bilevel positive airway pressure (BiPAP), Venturi mask, mechanical ventilator | Use the settings provided by the respiratory therapist and/or provider order. |
CPAP:
Endotracheal tube (ETT): Mechanical ventilator: |
| Bag valve mask |
Flow rate: 15 L/min FiO
2
: 100 percent
Squeeze the bag once every five to six seconds for an adult or once every three seconds for an infant or child. |
Refer back to Unfolding Case Study #3: Part 7 to review the patient data.
| Provider’s Orders |
1940:
Supplemental oxygen to maintain oxygen saturation greater than 92 percent
Insert peripheral IV Furosemide 20 mg IV × one dose Monitor and document accurate intake and output |
Patient Education
It is important to modify patient education methods depending on the individual’s knowledge, skills, and abilities. For example, some older adults readily engage in using electronic technology, but others have low digital literacy or experience difficulty when accessing electronic health resources. Nurses should adapt patient education to the needs of the individual and provide verbal, written, or electronic resources, as needed, while considering any sensory, cognitive, or functional impairments. The ultimate goal of health promotion and patient education is to improve their understanding, motivation, and engagement in self-management and promote their quality of life.
Behavioral Modifications
Knowing there are many behaviors that can negatively impact the cardiopulmonary system , it can be important for nurses to provide patient education about behavioral modifications. As part of the nursing history and physical, behaviors like smoking, exercise, nutrition, alcohol, and other intake of drugs, should all be discussed with the patient.
Helping the patient realize how certain applicable behaviors affected overall health, and cardiopulmonary health in particular, is important and can provide the necessary first step in recognition of the action-reaction relationship. Nurses are often the first providers of such information, as so much time is spent directly with patients, and relationships are established whereby patients feel comfortable asking questions. Once identified and recognized, the nurse can begin to introduce applicable information to help modify any negative behaviors.
There is a lot of information available regarding smoking cessation and many resources to help patients quit. Dietary recommendations can be provided, including cardiac diets, and recommendations for calorie intake in the presence of COPD. Patients may need guidance and contacts for support groups in order to consider quitting alcohol or illicit drug use. If expert information is needed, such as specific dietary limitations, the nurse can discuss with the prescribing healthcare provider about a consult with a specialist, in this case, a nutritionist or dietitian.
Pollutants
As patients are seen in outpatient settings or are preparing for discharge from acute inpatient care, exploration by the nurse should include environmental exposures the patient is prone to. Whether this is secondhand smoke, exposure to motor vehicle exhaust, coal dust, or smoke from fires of any variety, patients may not understand the importance of exposure prevention. Patients should know about warnings for poor air quality and actions to take to avoid exposure. Education about appropriate respiratory protection devices, when to don and doff them, and how to wear them correctly can be discussed. And for information beyond the scope of nursing practice, the nurse can teach patients how to find reliable resources.
Coping Techniques to Reduce Anxiety
Coping strategies are behaviors used to manage anxiety. Effective strategies control anxiety and lead to problem-solving, but ineffective strategies can lead to abuse of food, tobacco, alcohol, or drugs. Nurses teach and reinforce effective coping strategies.
The nurse should determine what techniques the patient has used historically, and together the nurse and patient can discuss which have been successful and which have not. This can lead to behavior modifications and introduce new and healthy recommendations for coping in stressful situations. Often techniques like slow, deep breaths can be helpful. Some patients respond well to distraction and imagining a pleasant place or recalling a fond memory. The nurse can also suggest to the patient and prescriber the possibility of pharmacological intervention for anxiety to be added or adjusted to the patient’s care plan.
Comfort Measures
Establishing and maintaining comfort can be vital to patients while they are battling illness, painful symptoms, and fear. Nurses should be aware that some physical problems cause pain or discomfort, and many diagnostic tests and interventions inflict pain upon patients, who may already be uncomfortable.
The nurse should remain mindful of not only the treatments and pharmacological interventions that will enhance those direct cardiopulmonary physical needs but also the addition of pain medications, anxiolytics, and hypnotics if and when needed. Sometimes the most basic of interventions can better meet a patient’s most basic needs: a warm bath, preferred music, or a visit from a pet may help reduce stress, enhance comfort, and assist with rest and healing.
Interdisciplinary Collaboration
Many patients with serious, life-limiting illnesses have common symptoms that the nurse can assess, prevent, and manage to optimize their quality of life. Good symptom management improves quality of life and functioning in all states of chronic illness. Nurses play a critical role in recognizing these symptoms and communicating them to the interdisciplinary team for optimal management.
Collaborating with physical, occupational, speech therapists, and nutrition specialists in the design and implementation of care planning truly enhances patient care and improves patient outcomes (Figure 18.26). The importance of establishing and fostering good relationships with all members of the interdisciplinary team is crucial to safe patient care. Important departments that ensure cardiovascular and pulmonary health are nutrition, cardiac rehabilitation, and chest physiotherapy.
Nutrition
Healthy nutrition helps to prevent obesity and chronic diseases, such as cardiovascular disease. By proactively encouraging healthy eating habits, nurses provide the tools for patients to maintain their health, knowing it is easier to stay healthy than to become healthy after disease sets in. When patients are recovering from illness or surgery, nurses use strategies to promote good nutrition even when a patient has a poor appetite or nausea. If a patient develops chronic disease, the nurse provides education about prescribed diets that can help manage the disease, such as a low-fat, low-salt, low-cholesterol diet for patients with cardiovascular disease.
Patients often need guidance from dietitians to understand, plan for, and follow their specific nutritional needs. Also, whether the patient is actively involved in dietary choices or limitations while hospitalized, the dietitian is involved in the preparation of menu items that meet the needs of all specific diets.
Similar to being aware of a patient’s needs in regard to prescribed medications, it is important for nurses to understand patients’ dietary requirements and restrictions. Awareness of a cardiac diet, for example, which has limitations relative to sodium and fats, helps nurses provide the correct diets as well as guide patients and families to understand choices and follow recommendations. Patients with significant respiratory illness, like late-stage emphysema, often have increased calorie needs and require supplements with meals to provide enough energy for the extra physiological needs. For those who have comorbidities like DM or renal disease, dietary restrictions and recommendations are added to their care plans, while in the hospital and on discharge. Nurses tend to be the providers of discharge education, so the ability to describe various diets and caloric needs is important.
Cardiac Rehabilitation
Patients who have substantial cardiac dysfunction, whether having had an MI, or from progressive deterioration like HF, or who are postoperative after surgery for valvular disorder or CABG, are usually prescribed cardiac rehabilitation. Depending on the length of hospitalization, the patient may be quite deconditioned, with anticipated needs for a variety of interdisciplinary therapies in order to gain some strength back and be well enough to return home. Others may not have had significant damage requiring complicated rehabilitation and various therapies. Such rehabilitation may or may not involve time as an inpatient at a dedicated rehabilitation unit or facility.
Many are able to begin their cardiac rehabilitation while inpatient and be taught exercises and activities to be done after discharge. Like physical therapy (which may also be ordered), many rehabilitation actions can be carried out at home by the patient and perhaps with assistance from a family member or friend. Often, there are outpatient visits for some time after discharge, to a cardiac rehabilitation agency, in order to check in, be evaluated, and adjust activities as indicated by patient status and tolerance.
Chest Physiotherapy
There are devices and techniques that can assist patients with maintaining pulmonary function and recuperating from illness or exacerbation of an illness. Previously introduced was the IS, which many patients receive shortly after admission, whether for a long stay in the hospital or merely an overnight stay. These devices are disposable so patients are encouraged to take the IS upon transfer or discharge and continue using it several times daily.
Other methods of chest or respiratory physiotherapy include valves like a flutter valve which use vibration or oscillation to assist with positive expiratory pressure and enhance airway clearance. There are also specialized vests that inflate and deflate and offer vibration and percussion. Percussion can also be done manually by using cupped hands and repeated dull strikes to the chest and back, or with manufactured devices that provide similar thumping to the chest and back.
The goal of these interventions is to loosen and mobilize secretions from smaller to central airways to enable their removal by coughing or postural drainage (positioning the patient to use gravity to allow secretions to drain) (Figure 18.27).
Emergency Interventions
When things go wrong with the cardiopulmonary system , the results can quickly be devastating or fatal. Of course, not all abnormalities are lethal, but an ability to recognize normal and therefore be able to identify abnormal (whether being able to define exactly what is wrong or not) is critical for nurses. It is also important to be vigilant about assessments and know what changes in a patient’s status are worthy of immediate follow-up. A few of the things that require urgent or emergent interventions follow in the next and final section of this chapter.
Chest Tube Insertion
Depending on the reason for the insertion of a chest tube, it may be urgent or emergent; it is not typically a routine intervention. Emergent chest tube insertion is perhaps most commonly done for a pneumothorax; hemothorax (or the mixture of hemopneumothorax) and chylothorax are also possibilities that necessitate a chest tube. The lungs have a limited amount of space within the thoracic cage, so situations that alter the area for lungs to inflate and deflate, and those that change the normal pressure, are problematic.
The location for chest tube placement is based on radiography, as pneumothoraces are visible on chest x-rays (Figure 18.28). The nursing role includes reassuring and frequently assessing the patient, providing medication for pain and anxiety, and assisting the physician (or advanced practitioner) with the procedure, including the setup of the chest tube system. The insertion is done under sterile technique, either at the bedside or in an operating room. The flexible tubing from the chest tube system needs to be attached to the chest tube itself, so the nurse holds the clean tubing and the provider who inserted the tube inserts the tube end into the system’s tubing.
A related emergency that requires the insertion of a chest tube for ongoing management is a tension pneumothorax. This develops suddenly and impacts the lung or lungs, heart, and blood vessels. Without immediate intervention, it can be quickly life threatening. Since time is limited before the provider takes the time for chest tube insertion, a large gauge needle is inserted in the second intercostal space and midclavicular line to allow air to escape and the lung to reinflate.
The video Chest Tubes—Nursing Management and Assessment Made Easy presents more information about chest tubes.
Cardiopulmonary Resuscitation
According to the AHA (2023), high-quality CPR is the principal contributor to post–cardiac arrest survival. Nursing students, as well as nurses at all levels—from licensed practical nurses through advanced practice nurses, are normally certified as BLS providers and recertify every two years. Depending on the cause of the arrest, and the subsequent status of the patient, interventions include rescue breathing, chest compressions, and use of an automated external defibrillator (AED) or manual defibrillator. Not all actions are indicated for all patients. For example, a patient who has suffered a respiratory arrest but has a pulse does not need chest compressions, and asystole is not a shockable rhythm. If the patient is pulseless, CPR is indicated, in order to perfuse the body, particularly the brain.
The animation CPR in Action shows the perfusion capabilities of high-quality CPR. It also illustrates what happens when CPR is not done adequately.
Defibrillation
Based on the term itself, defibrillation is the delivery of an electric shock to stop fibrillation (ineffective quivering movement of the heart muscle). Fibrillation, though, can occur in the atria or the ventricles, and atrial fibrillation (A-fib) is not typified as a “deadly rhythm.” If an electrical intervention is sought for the treatment of A-fib, it involves fewer joules of electricity and is termed cardioversion . Ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT) are nonperfusing rhythms, and defibrillation is indicated emergently. Usually, this is delivered as part of BLS or ACLS efforts and accompanies CPR.
In acute care settings, a cart for arrest situations, also called a code, or COR-0, is present on most or all patient care units. The cart contains a hard backboard to place under the patient to enhance the quality of chest compressions, airway devices and bag- valve masks of various sizes, emergency drugs, and a manual defibrillator/monitor. In many other settings, automated external defibrillators (AEDs) are available and can be used by laypersons, as the device offers step-by-step instructions. Those who are BLS certified have practiced with AEDs. Defibrillation delivers 150 to 300 joules (depending on the type of device), in an effort to essentially reset (depolarize) the heart and resume a more normal rhythm. Refer to the AHA’s guidelines and algorithms (linked in the previous heading) for defibrillator (shock) indications and timing.
A demonstration of defibrillation with an AED is presented in this video. Watch the rhythm examples, as they are from an actual patient. Also, the AHA guidelines and algorithms may be reviewed.
Intubation
When a patient is receiving general anesthesia prior to a procedure or surgery or is experiencing respiratory failure or respiratory arrest, an ETT is inserted by an advanced practitioner, such as a respiratory therapist, paramedic, or anesthesiologist, to maintain a secure airway. The ET tube is sealed within the trachea with an inflatable cuff, and oxygen is supplied via a bag valve mask or via mechanical ventilation .
Placement is verified with a CO 2 detection device to ensure it is in the airway and not the esophagus . Auscultation should be done to verify equal, bilateral breath sounds. A chest x-ray will be ordered and performed for definitive placement confirmation and also to verify the ETT is in the optimal position. The ETT is attached to an Ambu bag, and the patient’s ventilation is provided by squeezing the bag every six seconds to deliver breaths until a mechanical ventilator is available. At that point, the bag is disconnected from the ETT, and the mechanical ventilator circuit is attached. Nurses collaborate with RTs and healthcare providers regarding the overall care of the patient on a mechanical ventilator.
This video shows intubation, bagging, placement detection, and attachment of the ETT to a ventilator in an emergency. Watch the technique and landmarks used with the laryngoscope, how the ETT is passed through the vocal cords, and the postintubation actions.
Mechanical Ventilation
A mechanical ventilator is a machine attached to an ETT to assist or replace spontaneous breathing. Mechanical ventilation is termed invasive because it requires the placement of a device inside the trachea through the mouth, such as an ETT. Mechanical ventilators are managed by RTs via protocol or provider order. The FiO 2 can be set from 21 to 100 percent.
Intubation and mechanical ventilation are uncomfortable and distressing to the patient, so patients are customarily sedated with an anxiolytic (e.g., lorazepam or midazolam) or anesthetic-type (e.g., propofol) medication. These drugs help the patient achieve synchrony with the ventilator, allowing the ventilator to provide all, or most of, the ventilation support. Some ventilator settings are so contrary to normal physiological breathing that patients will require continuous IV neuromuscular blockade or chemical paralysis. This drug therapy allows for complete control of breathing by the ventilator, and it is vital to provide sedation for patients on paralytics. Intubated and ventilated patients are at increased risk for ventilator-associated pneumonia (VAP), and there are nursing care actions like maintaining patients with the head of the bed at 30 degrees minimum, frequent oral care, and proton-pump inhibitor therapy in order to prevent the occurrence of VAP.


2.8: Assignment- Histogram
We will use the Best Actor Oscar winners (1970–2001) to learn how to create a histogram using a statistics package, and practice what we’ve learned about describing the histogram.
Click here to see the entire dataset.
Instructions
Click on the link corresponding to your statistical package to see instructions for completing the activity, and then answer the questions below.
R | StatCrunch | Minitab | Excel | TI Calculator
Question 1:
Describe the distribution of the ages of the Best Actor Oscar winners. Be sure to address shape, center, spread and outliers.
Contributors and Attributions
- Concepts in Statistics. Provided by : Open Learning Initiative. Located at : http://oli.cmu.edu . License : CC BY: Attribution


3: Frederick Douglass (1818–1895)
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- Kim Allen Gleed
- Harrisburg Area Community College (HACC)
A human rights activist, Frederick Douglass encountered nineteenth century dichotomies that defined him as ‘other’ both in himself and his work.  The dominant white hegemony prospered in a land founded ostensibly on the principles of equality and freedom for all, but which in practice refused to accept the American populous as it then already was: multiracial. Douglass worked throughout his life to bring these principles of equality and freedom to all men and women in America.
Image \(\PageIndex{1}\): Frederick Douglass. (Public Domain; George Kendall Warren via Wikipedia )
Born a slave to Aaron Anthony (c. 1766–1826) at Holme Hill Farm in Talbot County, Maryland, Frederick Douglass was left to the care of his grandmother, Betsey Bailey, who was given the charge of all the enslaved children at Holme Hill Farm. His mother, Harriet Bailey, was hired out to labor off the plantation along with her four sisters. Douglass later expressed the importance of these women—especially his grandmother—to his life and sense of self. At the age of seven, Anthony moved Douglass to the main residence, thus permanently separating him from his grandmother.
After Anthony died, Douglass became the property of Thomas Auld (d. 1880). Auld sent him to Baltimore to live with his brother, Hugh. Hugh’s wife, unbeknownst to herself, made the first step leading to Douglass’s life’s vocation in freedom by teaching him to read. She was soon stopped by her husband, who understood the power of knowledge. Douglass nevertheless worked at teaching himself to read and write. He learned humanist principles from such texts as The Columbian Orator (1797), learned of Abolitionist efforts from the Baltimore American, and learned through Charles Lawson, a free black preacher, to take up the “great work” for which Douglass was destined.
In 1833, Douglass was returned to Thomas Auld to work on the plantation; Auld hired Douglass out to Edward Covey (1805–1875), a notorious slavebreaker, to fit Douglass for his enforced work. From Covey, Douglass learned violence; for months, Douglass was whipped daily. He then defended himself in a two-hour combat with Covey. The beatings ceased. Douglass’s work to escape slavery began. A failed escape attempt with five other slaves caused Douglass to be arrested and jailed in Easton. He then was returned to Hugh Auld, who hired Douglass out to the Baltimore shipyards where he learned the caulking trade. Douglass managed to save for himself some money from what he earned for Hugh Auld. With it, and with the aid of the free black Anna Murray (1813–1882), Douglass boarded a train for New York, wearing the clothes and bearing the legal papers of a free black sailor.
Murray joined him in New York, and the two married. They moved to New Bedford to avoid Douglass’s being recaptured as a fugitive slave. He also changed his last name and dropped his middle names, henceforth becoming known as Frederick Douglass. At New Bedford, he encountered a racism that prevented his earning a fair living through his trade. Despite his poverty, and the demands of his growing family, Douglass subscribed to William Lloyd Garrison’s abolitionist newspaper The Liberator. After hearing Douglass give an antislavery speech, Garrison hired him as an abolitionist lecturer.
Despite the dangers he faced as an escaped slave and from anti-abolitionists, Douglass lectured throughout the North. He also wrote his Narrative of the Life of Frederick Douglass which was published by Garrison’s American Anti-Slavery Society in Boston.  He continued lecturing as a recognized leader of the Abolitionist movement. In 1845 and 1846, he traveled to Great Britain on a speaking tour. Anti-slavery British friends purchased Douglass’s freedom in 1846. Between 1851 and 1863, he founded three African American newspapers, starting with The North Star (1847–1851).
Douglass followed his Narrative with two other versions, My Bondage and My Freedom (1855) and Life and Times of Frederick Douglass (1881, revised 1892), describing his continuing experiences and contributing to the ongoing national discourse on slavery among abolitionists like Garrison and Stowe. Because he supported John Brown’s attack on Harper’s Ferry, Douglass was forced to escape to safety to Canada and then Great Britain. After his return to America, he supported the Civil War, advocating enlisting blacks and himself recruiting black soldiers.
After the Civil war, he continued publishing and editing newspapers, served as a United States marshal, a recorder of deeds in Washington, D.C., and consulgeneral to the Republic of Haiti. He also criticized the Reconstruction policy, and supported women’s rights, giving his last speech at a women’s rights rally.
Thumbnail: Frederick Douglass in 1856, around 38 years of age. (Public Domain; unidentified photographer via Wikipedia )


12.2: Cardiovascular Diseases
Coronary artery disease (CAD)
Coronary artery disease (CAD) is the most common type of heart disease in the United States. For some people, the first sign of CAD is a heart attack. Therefore, taking steps to reduce your risk for CAD is essential.
Research suggests that CAD (also referred to as coronary heart disease, abbreviated CHD) starts when certain factors damage the inner layers of the coronary arteries. These factors include:
- Smoking
- High levels of certain fats and cholesterol in the blood
- High blood pressure
- High levels of sugar in the blood due to insulin resistance or diabetes
Causes of CAD
When damage occurs, your body starts a healing process. The healing may cause plaque to build up where the arteries are damaged. Plaque is made up of deposits of cholesterol and other substances in the artery. This progression of plaque build up is called atherosclerosis.
The buildup of plaque in the coronary arteries may start in childhood. Over time, plaque can narrow or block some of your coronary arteries. This reduces the flow of oxygen-rich blood to your heart muscle.
Eventually, an area of plaque can rupture (break open). If this happens, blood cell fragments called platelets will stick to the site of the injury and may clump together to form blood clots. Blood clots narrow the coronary arteries even more and worsen angina (chest discomfort or pain) or cause a heart attack.
Over time, CAD can weaken the heart muscle. This may lead to heart failure, a serious condition where the heart can’t pump blood the way that it should. An irregular heartbeat, or arrhythmia, also can develop.
If you or a loved one has CAD, watch this video to learn how to actively manage it while also reducing further risk:
YouTube Video: Living with and Managing Coronary Artery Disease. Located at:: https://www.youtube.com/watch?v=V8lEEqTvBk4&feature=youtu.be
Other Conditions Related to Heart Disease
Coronary artery disease is the most common type of heart disease, but there are many other conditions that affect the heart:
Acute coronary syndrome is a term that includes heart attack and unstable angina.
Angina, a symptom of coronary artery disease, is chest pain or discomfort that occurs when the heart muscle is not getting enough blood. Angina may feel like pressure or a squeezing pain in the chest. The pain also may occur in the shoulders, arms, neck, jaw, or back. It may feel like indigestion.
There are two forms of angina—stable or unstable:
- Stable angina happens during physical activity or under mental or emotional stress.
- Unstable angina is chest pain that occurs even while at rest, without apparent reason. This type of angina is a medical emergency.
Aortic aneurysm and dissection are conditions that can affect the aorta, the major artery that carries blood from the heart to the body. An aneurysm is an enlargement in the aorta that can rupture or burst. A dissection is a tear in the aorta. Both of these conditions are medical emergencies.
Arrhythmias are irregular or unusually fast or slow heartbeats. Arrhythmias can be serious. One example is called ventricular fibrillation. This type of arrhythmia causes an abnormal heart rhythm that leads to death unless treated right away with an electrical shock to the heart (called defibrillation). Other arrhythmias are less severe but can develop into more serious conditions, such as atrial fibrillation, which can cause a stroke.
Atherosclerosis occurs when plaque builds up in the arteries that supply blood to the heart (called coronary arteries). Plaque is made up of cholesterol deposits. Plaque buildup causes arteries to narrow over time.
Atrial fibrillation is a type of arrhythmia that can cause rapid, irregular beating of the heart’s upper chambers. Blood may pool and clot inside the heart, increasing the risk for heart attack and stroke.
Cardiomyopathy occurs when the heart muscle becomes enlarged or stiff. This can lead to inadequate heart pumping (or weak heart pump) or other problems. Cardiomyopathy has many causes, including family history of the disease, prior heart attacks, uncontrolled high blood pressure, and viral or bacterial infections.
Congenital heart defects are problems with the heart that are present at birth. They are the most common type of major birth defect. Examples include abnormal heart valves or holes in the heart’s walls that divide the heart’s chambers. Congenital heart defects range from minor to severe.
Heart failure is often called congestive heart failure because of fluid buildup in the lungs, liver, gastrointestinal tract, and the arms and legs. Heart failure is a serious condition that occurs when the heart can’t pump enough blood to meet the body’s needs. It does not mean that the heart has stopped but that muscle is too weak to pump enough blood. The majority of heart failure cases are chronic, or long-term heart failures.
The only cure for heart failure is a heart transplant. However, heart failure can be managed with medications or medical procedures.
Peripheral arterial disease (PAD) occurs when the arteries that supply blood to the arms and legs (the periphery) become narrow or stiff. PAD usually results from atherosclerosis, the buildup of plaque and narrowing of the arteries. With this condition, blood flow and oxygen to the arm and leg muscles are low or even fully blocked. Signs and symptoms include leg pain, numbness, and swelling in the ankles and feet.
Rheumatic heart disease is damage to the heart valves caused by a bacterial (streptococcal) infection called rheumatic fever.
Types of Strokes
The main types of stroke are:
- Ischemic stroke.
- Hemorrhagic stroke.
- Transient ischemic attack (a warning or “mini-stroke”).
Ischemic Stroke
Most strokes (85%) are ischemic strokes. If you have an ischemic stroke, the artery that supplies oxygen-rich blood to the brain becomes blocked.
Blood clots often cause the blockages that lead to ischemic strokes.
Hemorrhagic Stroke
A hemorrhagic stroke occurs when an artery in the brain leaks blood or ruptures (breaks open). The leaked blood puts too much pressure on brain cells, which damages them.
High blood pressure and aneurysms—balloon-like bulges in an artery that can stretch and burst—are examples of conditions that can cause a hemorrhagic stroke.
There are two types of hemorrhagic strokes:
- Intracerebral hemorrhage is the most common type of hemorrhagic stroke. It occurs when an artery in the brain bursts, flooding the surrounding tissue with blood.
- Subarachnoid hemorrhage is a less common type of hemorrhagic stroke. It refers to bleeding in the area between the brain and the thin tissues that cover it.
Transient Ischemic Attack (TIA)
A transient ischemic attack (TIA) is sometimes called a “mini-stroke.” It is different from the major types of stroke because blood flow to the brain is blocked for only a short time—usually no more than 5 minutes.
It is important to know that:
- A TIA is a warning sign of a future stroke.
- A TIA is a medical emergency, just like a major stroke.
- Strokes and TIAs require emergency care. Call 9-1-1 right away if you feel signs of a stroke or see symptoms in someone around you.
- There is no way to know in the beginning whether symptoms are from a TIA or from a major type of stroke.
- Like ischemic strokes, blood clots often cause TIAs.
- More than a third of people who have a TIA end up having a major stroke within 1 year if they don’t receive treatment, and 10%-15% will have a major stroke within 3 months of a TIA.
Recognizing and treating TIAs can reduce the risk of a major stroke. If you have a TIA, your health care team can find the cause and take steps to prevent a major stroke.
Contributors and Attributions
Public Domain Content
- Coronary Artery Disease. Authored by: Centers for Disease Control and Prevention. Located at: http://www.cdc.gov/heartdisease/coronary_ad.htm . License: Public Domain: No Known Copyright
- Managing CAD Video. Authored by: National Heart, Lung, and Blood Institute. Provided by: National Institutes of Health. Located at: https://youtu.be/V8lEEqTvBk4 . License: Public Domain: No Known Copyright
- Types of Stroke. Authored by: Centers for Disease Control and Prevention. Located at: https://www.cdc.gov/stroke/types_of_stroke.htm . License: Public Domain: No Known Copyright